First Time Evaluation Form

The information provided in this form is strictly confidential.

Please complete this form carefully. The information provided will help us build a personalised healthcare programme for you.

Please do not take any supplements for 2 meals prior to your first evaluation.

(fields marked with * are required)

Biographical Details

First Name*

Last Name*

E-mail*

Phone*

Mailing Address*

Blood Type*

Weight (Kg)

Height (cm)

Date of Birth*

Age (Years)

Gender

Current Occupation*

Previous Occupation(s)

Marital Status*

How many children?

Referring Practitioner

Chief Concerns

Please list your current health concerns and rate their severity (on a scale of 1 – 10, 10 being most severe)

Health History

Please provide a detailed timeline of your personal health history, from childhood. Include all major traumas (physical and emotional), operations and illnesses, the age you were and what changes you experienced in your health.

2500 characters remaining

Other Therapies

If you have tried therapies to help these issues in the past, what was successful and what was not?

1000 characters remaining

Medications

Please list any medications you are currently taking, including self-prescribed medications such as Panadol etc.

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Supplements

Please list supplements that you currently take and include brand names.

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Name:

Length of use:

Dose:

Health Overview

Energy

Please rate your current energy level (on a scale of 1-10, 10 being the highest energy)

Does your energy change through the day and if so how does the scale change:

Morning

Afternoon

Evening

Other:

Sleep

How is your sleep?

RestfulRestlessHard to get to sleepWake oftenGet up during nightBad dreams

Other

What time do you usually sleep?

How many hours per night?

Exercise

What kind of exercise do you do?

How often do you exercise?

For how long at a time?

Stress

Please rate your current stress level (scale of 1-10, 10 being highest)

What is the main reason for your stress?

What steps are you taking to reduce your stress level?

Emotional

Please list any psychological or emotional issues that you are currently experiencing.

How would you describe your overall mood?

Eyes & Ears

Do you wear glassesContact lensesHad laser eye surgeryCataractsGlaucomaPoor night visionWear hearing aidsHave impaired hearingPoor night visionTinnitus

Other

More info

Sunlight

Hours of natural sunlight you receive daily outside?

Hours of sunlight you receive daily through windows?

Hours spent daily under fluorescent lights?

Urination

How are your daily urinations?
2-3 hoursToo frequentSense of urgencyToo small amountToo large amountBurningDribblingUp several times at night

Other

Digestion

How is your digestion?
AdequatePoorAcid refluxBurp oftenGasBloatingBurning / pain in stomachPain before bowel movementNausea before bowel movement

Other

Bowels

Eliminations per day

Other

Additional info

Women's Health

Are you pregnant or breastfeeding?
YesNo

Date of last menstrual period

Are your periods regular?
YesNo

Cycle Length

Have you had a hysterectomy?
YesNo

Menstrual duration (days)

Are you going through menopause?
YesNo

How many children have you delivered?

Had an episiotomy or a C-section?
YesNo

What is your current form of birth control?

Had an epidural?
YesNo

Current or previous reproductive disorder?

Have you struggled with fertility/miscarriage?
YesNo

Are you planning on becoming pregnant in the next year?

Do you have a history of low Iron levels?
YesNo

Men's Health

Have you experienced a drop in muscular strength, drive or libido?
YesNo

Do you have difficulty urinating or have an enlarged prostate?
YesNo

If you answered yes, please explain further:

Pets

Do you have any pets?
YesNo

If so, what kind and how many?

Is it allowed in all areas of the house?
YesNo

On your bed?
YesNo

What do you feed your pet(s)?

Do you frequently de-worm your pets?
YesNo

If so how often?

Chemical Exposure

Personal Care & Household Products (please indicate products & brands)

Perfume/Cologne

Hair Product

Shampoo

Cleanser

Hand/Body Lotion

Toothpaste

Make-up

Hair Dye

Nail Polish Remover

Deodorant

Moisturiser

Soap

Shave Cream

Conditioner

Nail Polish

Other chemical exposure from personal care products

Dishwashing

Air Freshener

Fly Spray

Paint

Laundry Soap

Glass Cleaner

Pesticides

All-Purpose

Insecticides

Fertilisers

Toilet Cleaner

Herbicides

Bleach

Other chemical exposure (from garden, work, art chemicals, etc)

Electromagnetic Exposure

How many hours per day do you spend...

Watching TV
0

Computer use
0

On landline phone
0

On mobile phone
0

Wearing a pager
0

Wearing a headset
0

Wearing a watch
0

Wearing hearing aids
0

Travelling by vehicle
0

Body Systems

Tick the individual symptoms being experienced and indicate 1 to 5 degree of severity. 5 being very severe.

LY	I experience recurrent infections, sinusitis, post nasal drip or swollen lymph nodes...	0
LU	I experience recurrent respiratory infections, coughs, bronchitis, pneumonia, asthma...	0
LI	I experience bouts of diarrhoea, constipation, gas, bloating...	0
NE	I experience irritability, nervousness, trembling, anxiety, memory problems...	0
CI	I have cold fingers/toes, blood pressure problems, varicose veins, circulation issues...	0
AL	I react to pollens, moulds, foods, seasonal irritants, perfumes, animal dander...	0
TH	I have a slow metabolism, am always hungry, have low energy at specific times of day...	0
TW	I have mood swings, problems sleeping, am always cold, have chemical imbalances...	0
HT	I experience heart palpitations, pain in my chest, irregular heart beat...	0
SI	I have recurrent yeast infections, frequent antibiotic use, poor diet...	0
JT	I experience joint pain, stiffness, inflammation in my body...	0
PA	I have diabetes, blood sugar issues, irritability, shaking if I skip a meal...	0
SP	I experience chronic fatigue, recurring infections, get sick easily...	0
LV	I experience high cholesterol, wake up between 2-4am, indigestion after fatty meals...	0
SK	I have rashes, dryness or cracking, scaly patches, eczema, acne, psoriasis...	0
GD	I struggle with impotence, libido, miscarriages, sterility...	0
UB	I have recurring urinary tract infections, painful urination, leaking, urinary frequency...	0
KI	I experience swelling, gout, pain in the lower back, history of kidney stones...	0

Surgeries / Injuries

What surgeries, operations, traumas, car accidents, etc have you had?

2500 characters remaining

Have you ever had full body anaesthesia (ie. To remove tonsils, wisdom teeth, etc)?
YesNo

Do you have any surgical implants (breast implants, metal pins, plates, clamps etc)?
YesNo

Have you had elective surgery (rhinoplasty, tummy tuck, liposuction, mole removal, etc)?
YesNo

Do you have pierced ears or other body piercings?
YesNo

Do you have any tattoos?
YesNo

Scars

Please describe any scars on your body (major and minor ones)

2500 characters remaining

Personal Health Goals

How important is your health to you on a scale of 1-10 (10 being highest)?

How much confidence do you have in your body’s ability to heal itself given the right nutrients & natural therapies? On a scale of 1-10 (10 being high)?

How much confidence do you have in medical drugs, on a scale of 1-10 (10 being high)?

What is most important to you in a health practitioner team?

What are your specific health goals? (What do you really want?)

How much money do you spend per month on your health?

How far are you willing to commit to achieve your health goals? (Please be honest)

Don’t really want to change muchWilling to change a reasonable amount

Willing to change someWilling to do whatever it takes

Doshas – Vata / Pitta / Kapha

Energy Imbalances - Please tick the symptoms which you are experiencing regularly...

VATA

Please indicate total number of checks

PITTA

Please indicate total number of checks

KAPHA

Please indicate total number of checks

Dental Health

When was your last dental appointment and what treatments were done?

500 characters remaining

Do you have any dental concerns?

500 characters remaining

Do you currently have or have you ever had any amalgam/silver fillings?
YesNo

Do either of your parents have amalgam/silver fillings?
YesNo

Do you experience any of the following?

Receding gumsTooth painMouth ulcers

Bleeding gumsBad breath

Other symptoms?

Toxic Burden

Smoking

Do you currently smoke?

If yes, how much?

How long have you smoked?

Do you frequently breathe second-hand smoke from others who are smoking (either at home or work)?

Alcohol

Do you drink alcohol?

DailyWeekly

MonthlyNot at all

What do you drink and how much?

Recreational Drugs - This is strictly confidential information

Do you currently use recreational drugs?

Methamphetamine
Others?

Have you used recreational drugs in the past?

If yes, what and for how long?